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Difficulty: HardCardiothoracic and Vascular Surgery

A surgical service is evaluating multiple patients with suspected vascular or cardiothoracic conditions. Match each patient's clinical presentation with the underlying pathophysiologic mechanism or anatomic lesion most likely responsible for their symptoms.

  • A 62-year-old woman experiences dizziness and ataxia while vigorously scrubbing windows; examination reveals her left brachial systolic blood pressure is 35 mm Hg lower than the right.Stenosis of the proximal subclavian artery leading to retrograde flow in the ipsilateral vertebral artery
  • A 58-year-old male smoker reports new-onset impotence and bilateral gluteal pain after walking 50 meters; bilateral femoral pulses are non-palpable.Chronic atherosclerotic occlusion of the distal abdominal aorta and common iliac arteries
  • A 67-year-old man presents with sudden-onset tearing chest pain, a widening pulse pressure, and a new high-pitched decrescendo diastolic murmur at the right sternal border.Intimal tear of the ascending aorta with retrograde propagation disrupting the aortic valve commissures
  • A 74-year-old woman with paroxysmal atrial fibrillation develops sudden, severe right leg pain and pallor; ipsilateral pedal pulses are absent but contralateral pulses are 2+.Acute thromboembolic occlusion of a peripheral artery without underlying chronic atherosclerotic disease
  • A 69-year-old man develops calf pain exacerbated by walking downhill but relieved by walking uphill; resting and post-exercise ankle-brachial indices are 1.05 bilaterally.Compression of the spinal nerve roots exacerbated by lumbar extension

Answer

The correct matches align each clinical presentation with its precise anatomic or pathophysiologic mechanism, distinguishing between acute vs. chronic vascular pathology and non-vascular mimickers.
Each clinical vignette contains specific differentiating factors (e.g., blood pressure differentials, pulse symmetry, postural changes, murmurs) that uniquely identify the underlying mechanism. Synthesizing these clues is essential for distinguishing true vascular emergencies from chronic conditions or musculoskeletal mimickers.

Step-by-Step Solution

1
Analyze the patient with arm exercise-induced neurologic symptoms and unequal blood pressures.
Matches with subclavian artery stenosis causing retrograde vertebral flow.
This is the classic presentation of subclavian steal syndrome, demonstrating compromised posterior cerebral circulation provoked by upper extremity demand.
2
Analyze the patient with buttock claudication, absent femoral pulses, and impotence.
Matches with chronic distal abdominal aorta and common iliac occlusion.
This confirms the triad of Leriche syndrome, representing severe aortoiliac occlusive disease.
3
Analyze the patient with tearing chest pain and a new diastolic murmur.
Matches with ascending aortic intimal tear disrupting the aortic valve.
Tearing chest pain indicates aortic dissection; a new diastolic murmur signifies acute aortic regurgitation caused by retrograde propagation into the aortic root.
4
Analyze the patient with sudden unilateral limb ischemia and normal contralateral pulses.
Matches with acute thromboembolic occlusion without underlying chronic disease.
Sudden onset with a known embolic source (atrial fibrillation) and normal contralateral pulses strongly points to a macroembolus rather than in-situ thrombosis.
5
Analyze the patient with positional claudication and normal ankle-brachial indices.
Matches with spinal nerve root compression exacerbated by lumbar extension.
Pain exacerbated by walking downhill (extension) and relieved uphill (flexion) combined with normal ABIs confirms neurogenic claudication rather than peripheral arterial disease.

Key Concept

Vascular Surgery Clinical Presentations and Pathophysiology
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Topics

Cardiothoracic and Vascular Surgery

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